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Unit 4
Positioning
Clinical data of patients
Screening mammography
Diagnostic mammography
Augmentation
Reduction
Other (breast lift, tram flap etc.)
AEC Chamber is
moveable so that
the location may be
adjusted for the size
of the breast being
examined
Distinction
Screening mammography
Used to detect breast changes in women who have no sign, or
symptom, or observable breast anomalies
The goal is to detect cancer before any clinical signs are
noticeable.
At least two mammograms from different angles of each breast
Diagnostic mammography
To investigate suspicious breast changes, such as
a breast lump, breast pain, an unusual skin appearance, nipple thickening or
nipple discharge.
Screening Mammography
In positioning patients for a routine
screening mammogram, the following
views are considered standard for the exam:
Craniocaudal (CC)
Mediolateral oblique (MLO)
Screening Mammography
Proper breast positioning is based on an
understanding of the normal breast anatomy
and the normal mobility of the breast.
The mobile aspects of the breast are the
lateral and inferior margins;
the medial and superior margins are fixed.
Screening Mammography
While it is desirable to have the nipple in
profile on the routine views, the primary
goal in breast positioning is to show as
much tissue as possible.
Therefore, breast tissue should not be
sacrificed to show the nipple in profile. The
nipple should be shown in profile, in at least
one view. When the nipple is not shown in
profile on any view, an extra view for
nipple profile can be done.
Mammographic Views
CC Mammogram
(C)ranio(c)audal = head to feet
MLO Mammogram
RCC
RMLO
CC view Craniocaudal
Cranio - side closest to
the head
Retromammary space
Pectoral muscle
Skin reflection of
the cleavage
Retromammary space
IMF open
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Compression
Diagnostic Views
ML
CV
TAN
90O ML or LM
Spot compression
views
Magnification or spot
magnification
CV (cleavage) AT
(axillary tail),TAN
(tangential) ID
(implant displaced)
Craniocaudal
Craniocaudal (CC) projection:
This view visualizes the breast looking down from
the top of the patient.
The anatomy visualized in this projection is
mainly for the medial aspect of the breast.
The technologist and radiologist are able to
determine where in the breast an abnormality lies,
whether it is medially or laterally placed.
It can not be determined from this view alone,
where an abnormality lies superiorly or inferiorly.
Craniocaudal
The craniocaudal (CC) position is best
accomplished when the R.T. stands on the medial
aspect of the breast being positioned.
Lift the mobile inframammary fold (IMF) as high
as its natural mobility will allow.
Raise the cassette holder to meet the edge of the
elevated IMF.
With one hand under the breast and the other on
top of the breast, gently pull breast tissue away
from the chest wall and position the nipple in the
center of the cassette holder.
Craniocaudal
With one hand placed on top of the breast near the
chest wall, hold the breast in this position. Lift the
contralateral breast, rotating the patient until the
chest wall edge of the bucky is flush against the
sternum.
Drape the contralateral breast over the corner of
the cassette holder (rather than placing it behind
the cassette holder).
Bring the patients head forward around the tube
assembly. This will enable the patient to lean in to
the machine, in order to position the superior
breast tissue over the image receptor.
Craniocaudal
Place the other hand, not holding the breast,
behind the patients back, to keep her from
pulling away from the mammography unit.
As compression is applied, the hand on top
of the breast gently pulls the tissue forward
to prevent wrinkles in the skin from
occurring.
Craniocaudal
It is important to have the patient relax the arm of
the breast being imaged. This will allow more
lateral breast tissue to be imaged. If wrinkles
appear, on the lateral side of the breast, use one
finger to laterally smooth them out.
Do not push the wrinkles back towards the chest
wall. This would move breast tissue out of the
image.
CC of a 19 y/o patient
CC of a 42 y/o patient
Craniocaudal
The CC projection may need to be modified with
more challenging patients.
Male patients have very little breast tissue to
manipulate; it is best to try gently pinching the
tissue around the areola, to maximize the amount
of tissue being imaged.
In patients with pacemakers or port-o-caths, may
be challenging to position, it is best to try
maximizing the amount of tissue being imaged,
without compromising the object in the chest.
Mediolateral Oblique
The mediolateral oblique (MLO) offers the
best opportunity to visualize the maximum
amount of breast tissue in a single view.
For the MLO, the plane of the cassette
holder can be angled anywhere from 30 to
60 degrees from the horizontal, so that the
cassette is parallel to the pectoral muscle.
Mediolateral Oblique
The criteria on the mammogram indicating that
positioning for the MLO is optimal include:
pectoral muscle is wide superiorly with a convex
anterior border, extending to or below the posterior
nipple line;
fat is visualized posterior to all of the fibroglandular
tissues;
deep and superficial breast tissues are well separated;
close inspection shows no evidence of motion blur; and
the inframammary fold is open.
Mediolateral Oblique
In the MLO projection, the X-ray beam is directed
from the superomedial to the inferolateral aspect
of the breast. In order to image the maximum
amount of tissue, it is imperative that the angle of
the image receptor is parallel to the angle of the
pectoral muscle of the individual patient.
To determine the angle of the pectoral muscle, the
technologist places her fingers in the patients
axilla behind the muscle. The patients shoulder is
should be relaxed in neutral rotation.
The technologist gently moves the pectoral muscle
forward to accentuate the movable lateral border.
Mediolateral Oblique
In the MLO projection, tall and thin patients
typically use a steeper angle (50 to 60
degrees).
Short and heavy patients typically use lesser
of an angle (30 to 40 degrees).
If the pectoral muscle is not parallel to the
image receptor, less tissue will be imaged.
Mediolateral Oblique
Applying the principle of moving the mobile tissue
toward the fixed tissue, lift the breast, then pull both
breast tissue and the pectoral muscle anteriorly and
medially.
The patients hand on the side being imaged should
be resting on the handlebar. Move the patients
shoulder as close to the center of the bucky as
possible.
This will place the corner of the cassette holder
posterior to the axilla, behind the pectoral muscle,
but in front of the latissimus dorsi.
Mediolateral Oblique
The patients arm is draped behind the cassette
holder to relax the pectoral muscle.
Rotate the patient toward the cassette holder so
that the edge of the cassette holder replaces your
hand in maintaining the breast and muscle in its
mobilized position.
Hold the breast up and out, away from the chest
wall to prevent overlapping of tissue.
Begin to apply compression.
While compressing, have the patient move their
hips and feet in toward the mammography unit.
Mediolateral Oblique
The upper corner of the compression paddle
should be just below the clavicle. While moving
your hand out of the field, continue to support
the anterior aspect of the breast with your hand
until there is enough compression to maintain
the breast in this position.
We call the combined hand movements the out
and up maneuver. It is very important to use
this technique, otherwise breast tissue will
overlap as a result of improper technique.
Mediolateral Oblique
The final step in positioning the MLO projection
of the breast involves pulling abdominal tissue
down in order to open the inframammary fold.
The entire breast, from inframammary fold to
axilla, should be centered on the cassette holder.
The photo cell should be placed at the level of the
retroareolar tissue. This is the most dense area of
the breast.
Mediolateral Oblique
In special circumstances, you may be working
with an obese patient. In these cases, try to push
as much of the abdominal tissue back behind the
image receptor, after compressing the breast.
You may also be working with patients with
pectus excavatum. These patients may be difficult
to position, so a reverse MLO may be necessary.
This is called an LMO. This view will improve
visualization of medial breast tissue.
Craniocaudal
Medio Lateral
Oblique
Lateral
Ninety degrees or true lateral ( or straight lateral)
projection: is the most commonly used additional view.
This view is used to triangulate the exact location of
lesions in the breast.
The 90 degree lateral view is also used to demonstrate
gravity-dependent calcifications. (Milk of calcium).
When an abnormality shows on one standard view but
not the other (CC or MLO), a lateral view is taken to
determine if the abnormality is real, superimposed
tissue, artifact on the radiograph, or in the skin.
Lateral
A change in location of a lesion relative to
its distance from the nipple of the 90 degree
lateral view can be used to determine
whether the lesion is in the lateral, central,
or medial aspect of the breast.
When an abnormality has been identified,
the most appropriate lateral view, medial to
lateral versus lateral to medial, is the one
that provides the shortest object-to-image
receptor distance, to reduce geometric
unsharpness.
Lateral
Medial-to-lateral 90 degree lateral projection
The tube arm is rotated 90 degrees. The
patients arm on the side being examined is
abducted 90 degrees resting across the top of
the cassette holder.
Lateral
Pull the breast tissue and pectoral muscle
anteriorly and medially. Lift the breast out and
up while gently pulling the breast away from the
chest wall.
Rotate the patient toward the cassette holder and
begin compression. Continue to compress, while
holding the breast tissue up and out away from
the chest wall.
When you are finished compressing, pull down
on the abdominal tissue, to open up the
inframammary fold.
Lateral
For the lateromedial view, the tube arm is
90 degrees with the top of the cassette
holder at the level of the suprasternal notch.
The patient is positioned with her sternum
against the edge of the cassette holder, her
neck extended with her chin resting on the
top of the cassette holder.
Lateral
Pull the mobile lateral and inferior tissue up and
toward the cassette holder. Bring the
compression paddle down past the latissimus
dorsi, lift the patients arm on the side being
imaged over the cassette holder.
Continue rotating the patient until the breast is
in a true lateral position centered on the cassette
holder. Open the inframammary fold by gently
pulling abdominal tissue down.
Spot Compression
Spot or coned compression is a simple
technique. It is especially helpful with
obscure or equivocal findings in areas of
dense tissue.
Spot compression allows for more localized
compression of an area of the breast. It
allows for higher contrast, and more precise
evaluation of findings.
Spot Compression
Using the original mammogram, the technologist
determines the placement of the small
compression device by determining the location of
the lesion.
To determine the location of the lesion, measure
the depth relative to a line drawn directly posterior
from the nipple, the distance from that line to the
lesion in the superior-to inferior or medial-tolateral direction, and the distance from the lesion
to the skin surface.
Spot Compression
Reposition the patient, using your hand to
simulate compression.
Transfer the three measurements to the
breast and use a marker to identify the
location of the lesion.
Reposition to center the spot compression
device over the lesion.
Spot compression of
suspicious area
containing
microcalcifications
Cleavage (CV)
The cleavage view (valley view, double
breast compression view) is performed to
visualize deep lesions in the posteromedial
aspect of the breast.
The patients head is turned away from the
side of interest.
Cleavage (CV)
Positioning is done with the technologist standing
behind the patient, and wrapping her arms around
the patient to reach her breasts. Make sure to pull
all of the medial tissue of both breasts anteriorly in
order to image the cleavage.
Automatic exposure can be obtained, by placing
the breast of interest over the photocell with the
cleavage slightly off center.
Manual technique must be used if the photocell is
under an open cleavage.
Tangential (TAN)
This view is used for palpable lesions that are
obscured by surrounding dense glandular tissue on
the mammogram. The C-arm is rotated and the
patient is turned so that the X-ray beam is tangential
to the palpable lump.
These views can be obtained by placing a lead
marker (BB) directly over the lump and directing the
X-ray beam tangential to the lead marker.
These views can also be used to verify that
calcifications seen on a mammogram are located
within the skin.
Mediolateral oblique
projection for AT of a
68-year-old woman,
demonstrating illdefined stellate mass
measuring 8 mm
Craniocaudal
projection with
roll lateral
(RL)
Superolateral to inferomedial
oblique (SIO)
This is an oblique view that can be
performed with the central ray directed
upper-outer to lower-inner.
This view has been incorrectly termed as a
reverse oblique. As a whole-breast
projection it has limited usefulness.
Caudocranial projection
performed in a 57-yearold woman to facilitate
the shortest route for
localizing a lesion
identified in the inferior
aspect of the breast
Magnification (M)
Magnification views with or without spot
compression can be helpful in differentiating
benign from malignant lesions by permitting a
more precise evaluation of margins and other
architectural characteristics of a focal density or
mass.
These views also permit better delineation of the
number, distribution and morphology of
calcifications.
Magnification (M)
To perform magnification views, there has to be an
X-ray tube with a micro focal spot to offset the
geometric unsharpness. It also requires a
magnification platform to separate the compressed
breast from the cassette for a 1.5 to 2.0 times
magnification. In making the exposure, the patient
will need to hold still longer than for a normal
mammogram.
The air gap resulting from separation of the breast
from the image receptor prevents a significant
amount of scattered radiation from reaching the
image receptor, and a grid is not used.
Magnification